Tenderness.
—Tenderness is a more constant and persistent and, therefore, a more reliable indication than pain, and, as well, less misleading. No matter where the patient may seem to feel pain the actual tenderness will indicate the location of the appendix itself. Thus even if pain on the left side be severe, tenderness will not accompany it, but will be found centred at the location of the appendix. This is a fact of great importance. In his first paper on appendicitis McBurney showed that the appendix is most commonly located at a point beneath a line drawn from the umbilicus to the anterior superior spine and one and a half or two inches away from the latter. This has since been known as McBurney’s point. To it, however, too much importance should not be attached, since the appendix is often not found under this area, and tenderness may be found at a distance two or three inches away from it. Over the actually tender area the skin will also be hypersensitive, and this intense hyperesthesia is also an indication of considerable value.
Rigidity and Muscle Spasm.
—Rigidity and muscle spasm are to be carefully studied, and upon them much reliance may be placed. With the first onset of pain they may be general, but they usually become more and more localized, unilateral, and finally limited, save in those instances where general peritonitis has begun and is spreading. For instance, Richardson regards it in this light: “Rigidity with distinctly localized pain strongly suggests appendicitis; with fever it almost proves it; with tumor it fully establishes diagnosis.” When to ordinary abdominal rigidity is added actual muscle spasm, provoked by even light palpation, and occurring in the rectus or one of the flat muscles lying in close relation to the appendix, then a still more important indication has been obtained. When true muscle spasm involves all the abdominal musculature general peritonitis has probably begun.
Tumor.
—The presence of tumor in the suspected area will nearly always be a corroborative sign, but diagnosis should not depend upon its presence. It is hardly to be looked for during the early hours or perhaps days of an ordinary attack. It may be due to fecal impaction in the cecum, to outpour of exudate, to binding together of omentum and intestine, or to the presence of pus. If a considerable mass can be detected within the cecum during the early hours of an attack this should be regarded rather as an expression of coprostasis and impaction, to which the attack itself may be due. Tumor, therefore, is significant when present, while in some instances its absence is still more so.
Vomiting.
—Vomiting is an irregular and uncertain feature. Probably the majority of cases begin with nausea (after the initial pain) or with vomiting, either one without the other, or with both combined. Likely through the course of the disease vomiting may be an occasional disturbing element, though patients may have no nausea whatever.
Bowels.
—The condition of the bowels and their behavior will depend very much upon their actual state at the moment of attack. Some attacks seem precipitated by violent intestinal activity; here diarrhea or dysentery will be an early feature. Others are precipitated rather by overloading of the cecum; in these cases constipation would be a well-marked feature. Bowel inactivity is to some extent an expression of bowel paralysis due to toxemia, which in some instances is profound, in others slight.